Introduction

Diabetic foot disease is a major public health problem with an annual NHS expenditure in excess of £1 billion. Infection increases risk of major amputation fivefold. Due to the polymicrobial nature of diabetic foot infections, it is often difficult to isolate the correct organism with conventional culture techniques, to deliver appropriate narrow spectrum antibiotics. Rapid DNA-based technology using multi-channel arrays presents a quicker alternative and has previously been used effectively in intensive care and respiratory medicine.

Introduction

Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres.

Aim

This retrospective case series reports the reoperation, major amputation, survival rates and mobility status in diabetic patients who underwent a trans-metatarsal amputation (TMA) managed within a multi-disciplinary diabetic foot care service.

Introduction

Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair.

Aims

This prospective cohort study aimed to determine if the size of the tendon gap following acute tendo Achillis rupture influences the functional outcome following non-operative treatment.

Summary Statement

DNA damage induced by systemic drugs or local γ-irradiation drives disc degeneration and DNA repair ability is extremely important to help prevent bad effects of genotoxins (DNA damage inducing agents) on disc.

Introduction

The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery.

Increasing knee flexion following total knee arthroplasty (TKA) has become an important outcome measure. Surgical technique is one factor that can influence knee motion. In this study, it was hypothesised that stripping of the posterior knee capsule could improve flexion and range of motion (ROM) following TKA. Patients who were undergoing TKA were prospectively randomised into two groups - one group (62 patients) were allocated stripping of the posterior knee capsule (PCS), the other group (66 patients) no stripping (no-PCS). The primary outcome was change in flexion and ROM compared to pre-operative measurements at three time points; after wound closure, 3months and 1year post-operatively. Secondary outcomes were absolute measurements of flexion, extension, ROM and complications. All operations were performed by a single surgeon using the same implant and technique. All patients received identical post-operative rehabilitation. There was a significant gain in flexion after wound closure in the PCS group (p=0.022), however there was no significant difference at 3months or 1year post-operatively. Absolute values of extension (p=0.008) and flexion (p=0.001) 3months post-operatively were significantly reduced for the PCS group. The absolute value of ROM was significantly higher for the no-PCS group at 3months (p=0.0002) and 1year (p=0.005). There were no significant difference in the rate of complications. Posterior capsular stripping causes a transient increase in flexion that does not persist post-operatively. We do not recommend routine stripping of the posterior knee capsule in patients undergoing TKA.

The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. In March 2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst members of the British Orthopaedic Foot and Ankle Society (BOFAS).

The response rate was 53%. The total the number of elective foot and ankle operations performed by the surveyed group was 33,500 per annum. The perceived incidence of DVT, PE and fatal PE was 0.6%, 0.1% and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although this figure is open to significant bias.

The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on reducing the risk of venous thromboembolism in surgical patients. These guidelines cover all surgical inpatients and uses data extrapolated from other groups of patients. We question the applicability of these guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the use of chemical thromboprophylaxis.

Introduction

Osteochondral defects of the talus are usually a consequence of trauma. They can cause chronic pain and serious disability. Various interventions, non-surgical and surgical, have been used for treating these defects. The objective of this Cochrane systematic review of randomised control trials is to determine the benefits and harms of the interventions used for treating osteochondral defects of the talus in adults.

The aim of this study was to compare immediate weight-bearing mobilisation with traditional plaster casting in the rehabilitation of non-operatively treated Achilles tendon ruptures.

Forty-eight patients with Achilles tendon rupture were randomised into two groups. The treatment group was fitted with an off-the-shelf carbon-fibre orthotic and the patients were mobilised with immediate full weight-bearing. The control group was immobilised in traditional serial equinus plaster casts. The heel raise within the orthotic and the equinus position of the cast was reduced over a period of eight weeks and then the orthotic or cast was removed. Each patient followed the same rehabilitation protocol. The primary outcome measure was return to the patient's normal activity level as defined by the patient.

There was no statistical difference between the groups in terms of return to normal work [p=0.37] and sporting activity [p=0.63]. Nor was there any difference in terms of return to normal walking and stair climbing. There was weak evidence for improved early function in the treatment group.

There was 1 re-rupture of the tendon in each group and a further failure of healing in the control group. One patient in the control group died from a fatal pulmonary embolism secondary to a DVT in the ipsilateral leg.

Immediate weight-bearing mobilisation provides practical and functional advantages to patients treated non-operatively after Achilles tendon rupture. However, this study provides only weak evidence of faster rehabilitation.

Context: Diabetes is associated with a several fold increase in the risk of lower extremity amputation. Although a number of epidemiologic studies have reported positive associations between glycaemia and lower extremity amputation, the magnitude of the risk has not been adequately quantified.

Objective: To synthesize the available prospective epidemiologic data on the association between glycaemia as measured by glycosylated haemoglobin and lower extremity amputation in individuals with diabetes.

Data Sources: We searched electronic databases (MED-LINE and EMBASE) and the reference lists of relevant articles.

Study Selection: We considered prospective epidemiologic studies of cohort or nested case-control design that measured glycosylated haemoglobin level and assessed lower extremity amputation as an outcome. Of 2,398 citations identified, we included 14 studies comprising 94,640 subjects and 1,227 cases.

Data Extraction: Data were abstracted using standardized forms or obtained from investigators when published information was insufficient. Data included characteristics of case and control populations, measurement of glycaemia, assay methods, outcome, and covariates.

Results: The overall risk ratio for lower extremity amputation was 1.26 (95% CI, 1.16–1.36) for each percentage point increase in glycosylated hemoglobin level. There was significant heterogeneity across studies (I2: 76%, 67–86%; p< 0.001) not accounted for by recorded study characteristics. Among studies that reported the type of diabetic population, the combined estimate was 1.44 (1.25–1.65) for individuals with type 2 diabetes and 1.18 (95% CI, 1.02–1.38) for type 1 diabetes, but the difference was not statistically significant (p=0.09). We found no significant publication bias.

Conclusions: There a substantial increase in risk of lower extremity amputation associated with every 1% higher HbA1c in individuals with diabetes, highlighting a potential benefit of blood glucose control. In the absence of evidence from clinical trials, this paper supports glucose-lowering as a component of overall care in the patient at high risk of amputation.

Background: This study compares two diaphyseal osteotomies (scarf and Ludloff) which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow up at twelve months.

Materials and Methods: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardised weight bearing radiographs were analysed.

Results: There was no stastically significant difference between the two groups at 6 and 12 months in subjective satisfaction, AOFAS score, improvement in functional activities and range of movements. The improvement in pain (at best) and transfer lesions at 12 months was significantly better in the scarf group (p< 0.05). The radiological results at 6 and 12 months including intermetatrsal angle (p< 0.001), hallux valgus angle (p< 0.01), distal metatarsal articular angle and seasmoid position (p< 0.05) were significantly better in the scarf osteotomy group. There were three cases (5%) of delayed union in the Ludloff group. Two of these healed with dorsiflexion malunion. One patient in the Ludloff osteotomy group developed a complex regional pain syndrome. There were two wound complications in the scarf group.

Conclusion: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months.

Introduction: Ankle syndesmotic injury is currently assessed by radiographic criteria defined by Pettrone. These indices are based on the assumption that the ankle is in the correct rotation when the radiographs are taken. This study shows that computerized tomographic (CT) scans of an ankle in its mortice orientation demonstrate a greater range of values for the tibio-fibular overlap (TFO), and the tibial clear space (TCS) than that proposed by Pettrone. This study also demonstrates how rotation of the ankle in the transverse axis changes the values for the TFO and TCS.

Materials and Method: 20 uninjured ankle CT scans were studied to evaluate the syndesmosis. The images were orientated so that measurements were taken 1cm above the tibial plafond with the ankle in a mortice orientation. Each image was rotated 5° from 15° external rotation to 20° internal rotation. Bony landmarks were confirmed prior to taking measurements. These were taken by 2 orthopaedic surgeons on 2 separate occasions.

Results: The range for the TFO is 0–11.6mm; the range for the TCS is 2–6.1mm. The range for the values is greater than that proposed by previous studies. The TFO and TCS change with rotation of the leg.

Conclusion: On the AP radiograph syndesmotic disruption is indicated by a TCS > 5mm, a TFO < 10mm and on the mortise view a TFO < 1mm. A normal ankle should therefore have a TCS less than 5mm and TFO greater than 10mm on the AP and greater than 1mm on the mortise view.

There is a greater normal range of syndesmotic width found on CT scans than suggested by previous studies. Values change with rotation of the leg in its transverse plane. Syndesmotic injury cannot be reliably diagnosed using the current radiological criteria.

Introduction: The Distal metatarsal articular angle (DMAA) is a radiographic measure of orientation of the first metatarsal articular surface, it is frequently used in the management of hallux valgus. There is a great deal of conflict regarding accuracy, reproducibility and validity of the DMAA within the literature. This study aims to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of first metatarsal rotation and the DMAA and to assess inter-observer reliability.

Materials/Methods: 34 seperate dry cadaveric first metatarsal bones were mounted onto a customized light-box/protractor allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5 degree increments of rotation between 30 degrees supination and 30 degrees pronation and 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each image; the data was collated for statistical analysis.

Results: The data was analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal. A strong statistically significant trend of increasing score with increasing pronation is observed, the relationship of which is approximately linear. There is a strong effect of inclination, but the strength of this varies with rotation this is amplified at higher inclinations. Inter-observor error was noted in line with other studies, the linear relationship is maintained.

Discussion: This study has shown that the distal metatarsal articular angle varies significantly, in an almost linear pattern, with axial rotation of the first metatarsal. Inclination of the first metatarsal is also shown to affect the magnitude of the angle.

This study does not refute the distal metatarsal articular angle as an entity, but does confirm the inaccuracy of extrapolating the DMAA from plain AP radiographs.

Distal tibial fractures may be satisfactorily held in reduction by fine-wire external fixation techniques, avoiding the need for open reduction and internal fixation. However, as the use of external fixation is associated with pin-site infection, extra-articular placement of the wires is recommended. This study assesses the proximal extension of the capsule of the ankle joint in order to provide information on the safety of wire placement for distal tibia fractures.

We recruited 7 patients who were electively scheduled for an MRI ankle investigation with the suspicion of osteochondral defect and/or meniscoid lesion. Patients with a history of ankle fracture or ankle surgery were excluded from the study. Just prior to MRI, the ankle joint was injected with 5 to 15 ml of contrast solution (1 mM dimeglumine gadopentetate). Selected fat-saturated T1-weighted MRI scans with sagittal, coronal and axial views were obtained. The site and proximal extent of the capsular reflection with reference to the anterior joint line were measured.

All contrast-enhanced MRIs of the ankle joint space were well defined and unambiguous. Proximal capsular extensions above the plane of the anterior joint line were noted at the antero-medial and antero-lateral aspect of the joint (mean 8.9 mm, range 4.9 to 13.4 mm) and at the tibia-fibular recess (mean 18.7 mm, range 13.3 to 23.6 mm), areas that are frequently traversed by wire insertion.

Conclusion: This in vivo contrast-enhanced MRI ankle study demonstrates an appreciable capsular extension above the joint line of the ankle. The proximal capsular extensions at the antero-medial and antero-lateral aspect of the joint and at the tibio-fibular recess run the risk of being traversed during fine-wire placement for distal tibia fractures. Surgeons using these techniques should be aware of this anatomy.

Aim The aim of this study was to compare immediate weightbearing mobilisation to traditional plaster casting in the rehabilitation of acute repaired Achilles tendon ruptures.

Methods 48 patients with acute repaired Achilles tendon ruptures consented to enter the trial. Patients were randomised into two groups. The treatment group were fitted with an off-the-shelf carbon-fibre orthotic and were mobilised fully weightbearing. The equinus position of the ankle joint was reduced over a period of 8 weeks and the orthotic was then removed. The control group were immobilised in traditional serial equinus plaster casts. The equinus position of the cast was reduced over the same 8 week period with weightbearing for only the last 2 weeks. The primary outcome measure was return to the patient’s normal activity level. An independent observer, blind to treatment, recorded secondary clinical, anthropometric and patient-centred outcomes. Follow-up was for one year.

Results There were 23 patients in the treatment group and 25 in the control group. Results show median in weeks (95% C.I.), p-values are based upon a log-rank test.

Return to sport was 39.0 (18.0 to 60.0) in the treatment group and 26.0 (40.0 to 90.0) in the control group, p = 0.341.

Return to normal walking was 12.0 (10.0 to 18.0) in the treatment group and 18.0 (18.0 to 22.0) in the control group, p < 0.001.

Return to stair climbing was 13.0 (10.0 to 15.0) in the treatment group and 22.0 (18.0 to 22.0) in the control group, p < 0.001.

Return to work was 9.0 (2.0 to 9.0) in the treatment group and 4.0 (1.0 to 13.0) in the control group, p = 0.984.

There were 2 re-ruptures of the tendon in the treatment group. One occurred when the patient slipped on ice whilst wearing the orthotic. The other whilst running 3 months after the initial injury. One patient who had an augmented tendon repair and then plaster casting, required plastic surgery for a major wound complication. In addition, there were 8 minor wound-related complications in the control group and 6 in the treatment group.

Conclusion Immediate weightbearing mobilisation provides practical advantages to patients after Achilles tendon repair. The median return to activity was significantly shorter in the treatment group for return to normal walking and return to stair climbing but not for return to work or sporting activity.

Aims: 1 To assess the histological changes in patients with Achilles tendinopathy. 2 To map the distribution of nerves and nerve endings within the Achilles tendon

Methods: Tendon biopsy specimens were taken from patients with spontaneous (ie previously painless) Achilles rupture patients and chronic painful tendinopathy patients. ‘Normal’ cadaveric /lacerated tendon biopsies were used for comparison. Sections were stained with H& E for basic histology. Immunolocalisation of nerve tissue was performed with 2 anti-neurofilament antibodies. Non-specific immunoglobulin was used as a negative control.

Results: The number of nerves and nerve endings found within the normal tendons and both groups of degenerate tendons was very low

Only 30% of the normal tendon sections showed any positive staining at all

Compared to 36% of ruptured tendon and 43% of the painful tendinopathy sections.

Conclusions: Tendon rupture and chronic painful tendinopathy biopsies ALL show widespread degenerative changes

There is a paucity of nerve tissue within these tendons, which may have implications for the neurogenic hypothesis of tendon degeneration

There appear be more nerve fibres in vascular areas of the painful tendinopathy biopsies

There may be more nerve fibres in the peritendinous tissue

Aim Pressure on inpatient beds can lead to high cancellation rates for inpatient elective orthopaedic surgery. The use of day surgery facilities is one way to overcome this problem. We set out to assess patient satisfaction after Scarf osteotomy, as a day case procedure, to help determine whether this is a valid routine practice.

Method Twenty-six consecutive patients (25 female and 1 male) undergoing Scarf metatarsal osteotomy, lateral release, medial capsulorraphy, and Akin osteotomy were prospectively followed up. Three patients had bilateral procedures resulting in 29 operations being performed. All had their surgery under midfoot block with intravenous sedation administered by an anaesthetist. All patients were discharged on the day of surgery with oral analgesia and contact details of the on-call orthopaedic registrar. A telephone interview and questionnaire were performed on day 3 and day 7 post-operatively.

Results Post-operative pain: seven patients (24%) had no pain, 15 (51%) mild pain, five (17%) moderate pain and two (6%) had episodes of severe pain. Twenty-eight patients (96%) were satisfied with their level of postoperative analgesia. Twenty-eight patients (96%) would have the surgery as a day case again. One patient would not due to post-operative nausea and vomiting.

Post-operative problems experienced by patients: 17 patients (58%) had no problems, six (20%) felt that their pain was a problem, five (17%) experienced bleeding/bruising and one (3%) felt faint.

Survey of medical services contacted by patients: 26 (89%) contacted no-one, one (3%) day surgery unit staff, two (3%) their GP and one (3%) the hospital.

Significance Scarf osteotomy can be successfully performed under midfoot block with a high degree of patient satisfaction. This has the potential to reduce cancellations due to inpatient bed shortage.

We describe 74 patients with disabling instability of the knee due to isolated anterior cruciate deficiency. None responded to conservative measures or correction of internal derangements. All patients were treated by replacement of the anterior cruciate ligament with the medial third of the patellar tendon as a free graft, supplemented by an extra-articular MacIntosh lateral reconstruction. A satisfactory outcome was found in 93% of knees after an average of 70 months follow-up. Cast immobilisation after operation, the interval between injury and reconstruction, the age of the patient and the severity of symptoms before reconstruction had no significant effect on the final outcome.